Provider Demographics
NPI:1407114069
Name:STEPHENS, KYLE A (MAE, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MAE, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40066-0516
Mailing Address - Country:US
Mailing Address - Phone:502-633-1315
Mailing Address - Fax:502-633-1316
Practice Address - Street 1:320 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1026
Practice Address - Country:US
Practice Address - Phone:502-633-1315
Practice Address - Fax:502-633-1316
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100250830Medicaid